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Page 1
OFFICE USE ONLYRevised 03/13/2015DateOriginal Amended
PERSONAL QUESTIONNAIRE
a. All principals to the license application must complete this questionnaire in full. (Lendors, donors, guarantors and managers must also complete this questionnaire.) b. If you are a lender,donor or guarantor you must state your relationship to the applicant. c. Make duplicate blank forms as necessary. d. Answer all questions below. e. Attach additional sheets if more space is needed.
NAME OF APPLICANT
1. STATEMENT OF IDENTIFICATION
Print YOUR name: Date of birth
Residence street address County
City State Zip Code Cellular Phone
E-mail Address (Required): U.S. Citizen
NoYes
If NOT U.S. citizen - country of citizenship
If ALIEN, registration number or VISA type List any other names that you may have been known by (including maiden name)
HEIGHT
WEIGHT
SEX FEMALEMALE
HAIR COLOR
EYE COLOR
MARITAL STATUS
SPOUSE NAME
SPOUSE'S SOCIAL SECURITY #:
continued on next page
14
Residence Telephone
2. Position (or interest) you will hold (check each):
President
Vice President
Secretary
Treasurer
Chairman
Officer
Director
Manager
Partner
General Partner
Limited Partner
Sole Proprietor
Stockholder
LLC Member
LLC Manager
Lender*
Donor*
Guarantor*
*If Lender, Donor or Guarantor state your relationship to the applicant.
Social Security Number
Other
ABC Officer Joint Account Holder
Number of shares owned
Percentage of ownership
Page 2
OFFICE USE ONLYRevised 03/13/2015DateOriginal Amended
4. EMPLOYMENT HISTORY List your employment history for the past FIVE (5) years to the present date. Also, list any employment history that shows experience in the alcohol industry. Add additional sheets if necessary.
Employer
Employer Address
Type of business
Position
continued on next page
14
3. RESIDENCE HISTORY List your residence history for the past FIVE (5) years to the Present Date.
Address From (month/year) To (month/year)
Address From (month/year) To (month/year)
Address From (month/year) To (month/year)
Address From (month/year) To (month/year)
Print YOUR Name
To (month/year)From (month/year)
Employer
Employer Address
Type of business
Position
To (month/year)From (month/year)
Type of business
Employer AddressPosition
EmployerTo (month/year)From (month/year)
Page 3
OFFICE USE ONLYRevised 03/13/2015DateOriginal Amended
If you are an applicant (i.e. proprietor, partner, stockholder, officer or director) applicant's spouse, will you continue your present occupation or business?
Will you take an active part in the operation of the business to be licensed? NoYes
If YES, explain nature of activity and the hours you will devote to the business (hours, days, responsibilities):
Do you have any interest, direct or indirect, in any premises currently licensed by the Liquor Authority or business where any alcoholic beverage is manufactured, transported or sold at wholesale or retail whether by stock ownership, interlocking directors, mortgage or lien on, or ownership of any real or personal property, or by any other means including loans?
Yes
No
If YES, provide information below:
Business name Business address
Type of interest and date interest began Serial Number
Business name Business address
Type of interest and date interest began Serial Number
Business name Business address
Type of interest and date interest began Serial Number
continued on next page
14
Print YOUR Name
5(b)
5(c)
5. LICENSE HISTORY / AFFILIATIONS
NoYes5(a)
Page 4
OFFICE USE ONLYRevised 03/13/2015DateOriginal Amended
Name of applicant Address of premises Date of filing
Serial Number Disposition
Name of applicant Address of premises Date of filing
Serial Number Disposition
NoYes
If YES, state action and date of action, and give details:
Are you a police commissioner or law enforcement/police officer?
If YES, provide details
14
Print YOUR Name
5(e)
5(f)
Address of premisesName of applicant Date of filing
Serial Number Disposition
Name of applicant Address of premises Date of filing
Serial Number Disposition
NoYes
Other than as itemized in 5c above, have you ever applied in New York State or anywhere for a license or permit to traffic in alcoholic beverages, including any application as a partnership, limited partnership, limited liability entity or corporation in which you are/were a principal?
Yes
No
If YES, provide information below:
5(d)
Has a license or permit listed above been REVOKED, CANCELED or otherwise Involuntarily Terminated?
Page 5
OFFICE USE ONLYRevised 03/13/2015DateOriginal Amended
SPOUSEYOU
If NO, attach a Certificate of Disposition by the court clerk for each case. If convicted of a felony, submit a Certificate of Relief from Disabilities, if available. Submit an Affidavit explaining all details.
SPOUSEYOU
14
6. CONVICTION RECORD AND PENDING CRIMINAL CASES
(a) Have you or your spouse ever been convicted of a crime addressed by the provisions of Section 126 of the ABC Law (see instructions for statutory disqualification) which would forbid a person to traffic in alcoholic beverages?
No
Yes
If YES, supply details
(b) Have you or your spouse ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony, misdemeanor, driving while intoxicated (DWI), or driving while
impaired (DWAI)?
(c) If you have previously been approved for a license and had been convicted of any felony misdemeanor or other type of offense except minor traffic infractions, were all convictions reported to the Authority?
(d) Are there any ARRESTS, INDICTMENTS or SUMMONSES PENDING against you or your spouse - including driving while intoxicated or impaired?
IF YES, PROVIDE COPY OF ACCUSATORY INSTRUMENT.
If YES, please state exactly what the relationship is (ie: family member, friend, employer, etc.))
If the applicant answers YES, attach a Certificate of Disposition by the court clerk for each case. If convicted of a felony, submit a Certificate of Relief from Disabilities, if available. Submit an Affidavit explaining all details.
No
Not Applicable
Yes
Print YOUR Name
No
Yes
No
Yes
YOU SPOUSE
No
Yes
YOU SPOUSE
8. Signature:
7. Do you have any relationship with the current/previous licensee or any of the principals of the licensee? NoYes
Yes
No
Yes
No
Not Applicable
No
Yes
If the Spouse answers YES to this question, submit a Personal Questionnaire for the Spouse along with a Certificate of Disposition.
Dated